Social Security
Administration
Medicare
Prescription Drug Assistance
Receipt of Application
Wilkes-Barre Data Operation Center
PO Box 1020
Wilkes-Barre, PA 18767-1020
Date: November 5, 2005
Social Security Number: 123-00-6789
JOHN Q. PUBLIC
123 MAIN ST
SPRINGFIELD OH 45501
This
is a Receipt for Your Application for
Help
With Medicare Prescription Drug Plan Costs
We received your Application for Help with Medicare Prescription Drug Plan Costs and
will process it as quickly as possible. We will contact you if we need more information.